Attachment E CLAIM IMAGE_31SA_Redacted.pdf

578 KB Posted

Attached to
High Claims Medical Bill Auditor
Solicitation number
S000000320
Issued by
Pulaski County, Little Rock City, Arkansas

About this file

Written by GovTribe AI ·

This document appears to be a Claim Image file related to a medical billing claim for services provided to a Medicaid patient in Arkansas. The claim was submitted by Health Advantage, a payer, and processed by Medicaid Arkansas, the other payer. The claim includes detailed information about the patient's admission, diagnosis codes, service lines, and associated charges totaling $159,301.21.

The related state and local contract opportunity is for a High Claims Medical Bill Auditor to serve Pulaski County and the City of Little Rock in Arkansas. The contract would involve auditing high-value medical claims submitted to the county and city. No additional details are provided about the specific scope of work, response requirements, evaluation criteria, or contract term.

View the file

Other files

File Type Posted
Attachment A Business Associate Agreement~1.pdf PDF
Attachment J CLAIM IMAGE 2AZ0_Redacted.pdf PDF
Attachment O CLAIM IMAGE _2BFJ_Redacted.pdf PDF
S000000320 High Claims Medical Bill Auditor RFP.pdf PDF
S000000320 Official Solicitation Price Sheet.xlsx XLSX spreadsheet
Attachment C CLAIM IMAGE 2JZN_Redacted.pdf PDF
Attachment K EOB IMAGE _ 1624_Redacted.pdf PDF
Attachment M CLAIM IMAGE_26K2_Redacted.pdf PDF
Attachment N CLAIM IMAGE _ 2W7N_Redacted.pdf PDF
S000000320 Contract and Grant Disclosure.pdf PDF
S000000320 Sample Services Contract.pdf PDF
S000000320 Technical Proposal Packet.docx DOCX document
Attachment F CLAIM IMAGE _ 293O_Redacted.pdf PDF
Attachment G EOB 1095_Redacted.pdf PDF
Attachment H CLAIM IMAGE_3AZ6_Redacted.pdf PDF
Attachment I CLAIM IMAGE 38KY_Redacted.pdf PDF
Attachment L CLAIM IMAGE_26SP_Redacted.pdf PDF
Attachment P EOB IMAGE_0380_Redacted.pdf PDF
Attachment B Sample High Claims.pdf PDF
Attachment D CLAIM 2R72_Redacted.pdf PDF
Attachment Q EOB IMAGE_ 1791_Redacted.pdf PDF
Show all 21

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PAYER NAME INFORMATION

2010BB Entity Identifier Code PR - Payer 2010BB Entity Type Qualifier 2 - Non-Person Entity 2010BB Payer Name HEALTH ADVANTAGE 2010BB Identification Code Qualifier PI - Payor Identification 2010BB Payer Identifier BC01 2010BB Payer Address Line PO BOX 8069 2010BB Payer City Name LITTLE ROCK 2010BB Payer State Code AR 2010BB Payer Postal Zone or ZIP Code 722038069

CLAIM INFORMATION

2300 Total Claim Charge Amount 159301.21 2300 Facility Type Code 11 2300 Facility Code Qualifier A 2300 Claim Frequency Code 3 2300 Medicare Assignment Code A - Assigned

ANSI Page: 2

2300 Benefits Assignment Certification I... Y - Yes 2300 Release of Information Code Y - Yes, Provider has a Signed Statement

Permitting Release of Medical Billing Data Related to a Claim

2300 Statement 434 - Statement 2300 Date Time Period Format Qualifier RD8 2300 Statement Date 20200206-20200219 2300 Admission 435 - Admission 2300 Date Time Period Format Qualifier DT 2300 Statement Date 201906131317

2300 TYPE OF ADMISSION 1

2300 SOURCE OF ADMISSION 4

2300 PATIENT STATUS CODE 30

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABK

2300 Industry Code P285

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABJ

2300 Industry Code P285

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABN

2300 Industry Code Y712

2300 PRESENT ON ADMISSION INDICATOR N

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE DR - Diagnosis Related Group (DRG) 2300 Industry Code 004

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code P610

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code K2971

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code P612

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Q211

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J9382

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code Q250

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code D801

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code E2740

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code N136

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code T82534A

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code A0472

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code P0702

ANSI Page: 3

2300 PRESENT ON ADMISSION INDICATOR Y

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0002

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code P0726

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code P922

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code I959

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code P599

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code P2810

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code P271

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code K4090

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code R34

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code H35133

2300 PRESENT ON ADMISSION INDICATOR Y

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code B961

2300 PRESENT ON ADMISSION INDICATOR N

2300 CODE LIST QUALIFIER CODE ABF

2300 Industry Code J0410

2300 PRESENT ON ADMISSION INDICATOR N

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BI - Occurrence Span 2300 Industry Code 71 2300 Date Time Period Format Qualifier RD8 2300 Date Time Period 20190528-20190613

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BH - Occurrence 2300 Industry Code 11 2300 Date Time Period Format Qualifier D8 2300 Date Time Period 20190528

2300 HEALTH CARE DIAGNOSIS CODE 2300 0001HI 0001

2300 CODE LIST QUALIFIER CODE BE - Value 2300 Industry Code 80 2300 Monetary Amount 14.00

ATTENDING PROVIDER NAME INFORMATION

ANSI Page: 4

OTHER SUBSCRIBER INFORMATION

OTHER SUBSCRIBER NAME INFORMATION

OTHER PAYER NAME INFORMATION

2330B Entity Identifier Code PR - Payer 2330B Entity Type Qualifier 2 - Non-Person Entity 2330B Other Payer Last or Organization Na... MEDICAID ARKANSAS 2330B Identification Code Qualifier PI - Payor Identification 2330B Other Payer Primary Identifier 999990050 2330B Other Subscriber Address Line PO BOX 8002 2330B Other PAYER City Name LITTLE ROCK 2330B Other PAYER State Code AR 2330B Other PAYER Postal Zone or ZIP Code 72203

SERVICE LINE NUMBER INFORMATION

2400 Assigned Number 1

2400 INSTITUTIONAL SERVICE LINE 2400 0001SV2 0001

2400 Service Line Revenue Code 0174 2400 Line Item Charge Amount 69940.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 13 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-1 2400 Assigned Number 2

2400 INSTITUTIONAL SERVICE LINE 2400 0002SV2 0001

2400 Service Line Revenue Code 0174 2400 Line Item Charge Amount 6400.00 2400 BASIS FOR MEASUREMENT CODE DA - Days 2400 Service Unit Count 1 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-2 2400 Assigned Number 3

2400 INSTITUTIONAL SERVICE LINE 2400 0003SV2 0001

2400 Service Line Revenue Code 0250 2400 Line Item Charge Amount 32616.37 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1561 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-3 2400 Assigned Number 4

2400 INSTITUTIONAL SERVICE LINE 2400 0004SV2 0001

2400 Service Line Revenue Code 0258 2400 Line Item Charge Amount 60.14 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 2 2400 Line Item Control Number 6R - Provider Control Number

ANSI Page: 5

2400 Repriced Line Item Reference Number 1258795719-4 2400 Assigned Number 5

2400 INSTITUTIONAL SERVICE LINE 2400 0005SV2 0001

2400 Service Line Revenue Code 0270 2400 Line Item Charge Amount 1140.87 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 145 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-5 2400 Assigned Number 6

2400 INSTITUTIONAL SERVICE LINE 2400 0006SV2 0001

2400 Service Line Revenue Code 0272 2400 Line Item Charge Amount 888.22 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 32 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-6 2400 Assigned Number 7

2400 INSTITUTIONAL SERVICE LINE 2400 0007SV2 0001

2400 Service Line Revenue Code 0301 2400 Line Item Charge Amount 4126.60 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 17 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-7 2400 Assigned Number 8

2400 INSTITUTIONAL SERVICE LINE 2400 0008SV2 0001

2400 Service Line Revenue Code 0302 2400 Line Item Charge Amount 429.60 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 6 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-8 2400 Assigned Number 9

2400 INSTITUTIONAL SERVICE LINE 2400 0009SV2 0001

2400 Service Line Revenue Code 0305 2400 Line Item Charge Amount 566.00 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 9 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-9 2400 Assigned Number 10

2400 INSTITUTIONAL SERVICE LINE 2400 0010SV2 0001

2400 Service Line Revenue Code 0306 2400 Line Item Charge Amount 469.40 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 2 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-10 2400 Assigned Number 11

2400 INSTITUTIONAL SERVICE LINE 2400 0011SV2 0001

2400 Service Line Revenue Code 0320 2400 Line Item Charge Amount 824.75 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 5 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-11 2400 Assigned Number 12

2400 INSTITUTIONAL SERVICE LINE 2400 0012SV2 0001

2400 Service Line Revenue Code 0324 2400 Line Item Charge Amount 1476.50 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 5 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-12 2400 Assigned Number 13

2400 INSTITUTIONAL SERVICE LINE 2400 0013SV2 0001

ANSI Page: 6

2400 Service Line Revenue Code 0410 2400 Line Item Charge Amount 35779.40 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 131 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-13 2400 Assigned Number 14

2400 INSTITUTIONAL SERVICE LINE 2400 0014SV2 0001

2400 Service Line Revenue Code 0420 2400 Line Item Charge Amount 741.70 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 6 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-14 2400 Assigned Number 15

2400 INSTITUTIONAL SERVICE LINE 2400 0015SV2 0001

2400 Service Line Revenue Code 0430 2400 Line Item Charge Amount 754.20 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 6 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-15 2400 Assigned Number 16

2400 INSTITUTIONAL SERVICE LINE 2400 0016SV2 0001

2400 Service Line Revenue Code 0460 2400 Line Item Charge Amount 280.85 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-16 2400 Assigned Number 17

2400 INSTITUTIONAL SERVICE LINE 2400 0017SV2 0001

2400 Service Line Revenue Code 0470 2400 Line Item Charge Amount 1333.80 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 5 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-17 2400 Assigned Number 18

2400 INSTITUTIONAL SERVICE LINE 2400 0018SV2 0001

2400 Service Line Revenue Code 0483 2400 Line Item Charge Amount 1409.65 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-18 2400 Assigned Number 19

2400 INSTITUTIONAL SERVICE LINE 2400 0019SV2 0001

2400 Service Line Revenue Code 0771 2400 Line Item Charge Amount 63.16 2400 BASIS FOR MEASUREMENT CODE UN - Unit 2400 Service Unit Count 1 2400 Line Item Control Number 6R - Provider Control Number 2400 Repriced Line Item Reference Number 1258795719-19

ANSI Page: 7

File details come from the government source that posted it. Updated .